Once COVID-19 emerged in the U.S. in spring 2020, queries regarding healthcare design product cleanability were coming in “fast and furious,” said Mark Alan, senior vice president, product management and development at Inpro. While many cleaning solutions and chemicals had already been vetted by the building products manufacturer, others required tracking down increasingly hard-to-come-by disinfectants to conduct testing. “That was a great alert that [cleanability] was an important part of how to combat COVID-19,” Alan said during a Jan. 5 roundtable discussion hosted by Healthcare Design.

Alan joined a panel of professionals representing healthcare owners, designers, and product manufacturers who discussed the evolution of designing and specifying products to support the healthcare industry’s infection control initiatives as well as how the process will be redefined in the aftermath of COVID-19. Additional participants were Leilani Barkan, interior designer, Cleveland Clinic; Nancy Boldt, system manager furnishings, planning, design, and construction, Advocate Aurora Health; Meghan McBride, vice president, strategic accounts, healthcare, education, and government, Tarkett; Sylvia Nash, vice president, healthcare, Kwalu; Nan Schramm, associate partner, E4H Environments for Health Architecture; Dr. Thomas Schwieterman, vice president, clinical affairs and chief medical officer, Midmark Corp.; Jennifer Wilcynski, associate, Orcutt/Winslow; and Sarah Wolfe, creative director, contract, Crypton.

The group first explored the evolution of designing for infection control over recent years, including the growing need to support the reduction of healthcare-associated infections (HAIs) that’s been emphasized by payment models shifting toward avoiding never events such as infections. This has invited an industry-wide transition toward durable, cleanable, and seamless solutions—important components in an infection control strategy. For example, McBride said, fundamentals of infection control include cleaning and disinfection but also avoiding the creation of germ-breeding grounds in the first place (i.e., reveals, seams, crevices, etc.—areas that might require a toothbrush to clean).

Products designed to such standards ultimately helped stem the tide of COVID-19 calls that Alan described—for example, solutions with properties that inherently inhibit the growth of pathogens didn’t require adjustments and surfaces capable of withstanding chemical disinfectants such as quaternary ammonium were easily cleaned. Beyond that, manufacturers shared, companies worked to provide more accessible guidelines on cleaning protocols and enhanced existing offerings to meet pandemic-related needs. For example, Midmark offered complimentary contact tracing as part of its real-time location system (RTLS) services and Crypton enhanced its distribution of a proprietary fabric disinfectant.

Fortunately, Nash noted, COVID-19 is easy to kill. But how exactly the range of design products used within a healthcare space are cleaned and how materials perform against infection risk can range significantly. “I think, overall, what we need to be doing is a more bundled approach,” she said—for example, exploring options available that could provide a total solution for flooring, fabric, surfaces, etc. If anything, though, COVID-19 has inspired the need for true collaboration between design teams as well as healthcare staff members like environmental services (EVS), infection prevention, and nurses to identify what’s best. “In the past, it looks like [collaboration] was a checkmark. I think it needs to be more than that, and we just got a huge wake-up call with COVID-19 because there are worse things on the horizon,” Nash said.

An integrated approach

Part of pushing collaboration begins with having the right players at the design table, the group discussed. For example, Boldt said Advocate Aurora Health has included infection prevention staff in design meetings since before 2015, helping the team be mindful of specifics such as the workflow of a unit and how clinical staff will move through it. Meeting the organization’s sustainability standards as well as Healthier Hospitals Initiative requirements is yet another hurdle a product must clear. To that end, Boldt said she’s currently working with Inpro to develop a cubical curtain that’s wipeable and sustainable (all existing curtains were taken down immediately after COVID-19 and replaced with vinyl shower curtains for cleanability). “That’s where this level of cooperation needs to be—manufacturers, designers, but also the people on the frontlines,” Alan added.

It’s important to understand the role of EVS in the maintenance of specified products, as well—something that’s been realized even more so during COVID-19. For example, manufacturers might recommend that after a disinfectant is applied and dries, the surface should be wiped off to prevent damage to surfaces. “We found out even before this pandemic, that is not happening. Our staff doesn’t have the time,” Boldt said. Cleveland Clinic is facing a similar challenge, Barkan added. “We already see with our very durable products what a beating the cleaners take to them and that they’re not being wiped off. People are cleaning three to five to eight times as much right now, and I feel like we’re going to be in big trouble in two years trying to replace them,” she said.

Bringing a Canadian perspective to the conversation, McBride shared how in the aftermath of SARS, the country’s healthcare spaces saw a similar effect in products not standing up to the heavy disinfectants that were used. “Things just didn’t survive. And so that’s when our codes and standards started shifting to being ready to handle the worst-case scenario—you’re not supposed to bleach resilient floor, but it’s going to happen,” she said. “A pandemic is like a hurricane, so what do you need to do to be ready for a hurricane?”

However, McBride noted, the sustainability challenge that Boldt mentioned is likely to persist because organic materials that are inherently more sustainable can’t generally survive those worst-case scenarios. “Historically, and it’s changing with technology, the more organic material or the more sustainable, the less ability it has to withstand what was needed for infection control from a chemical point of view,” she said.

Recognizing the inevitable strain materials will be under, particularly in similar outbreak scenarios, Nash urged more consideration of surfaces, specifically—for example, wood and metal may deteriorate with harsh cleaning regimens and subsequently harbor germs (Kwalu uses solid surface in its furniture). “We need to get better at surfaces,” she said. And while that’s not the primary mode of transmission for COVID-19, Nash also warned of urgent threats on the Centers for Disease Control and Prevention’s radar, such as c. diff and c. auris, that do spread by surface contamination. “What we’re focused on right now needs to be the future, not COVID-19,” she said.

Alan said he’s also interested in the promise of antimicrobials to inhibit the growth of microorganisms, despite more data and science being needed to support the yet-unproven application in healthcare spaces. “I don’t want to throw that to the side and say that’s not a solution for us. The biggest reason for that, too, is we don’t know what’s to come yet. My biggest fear has always been microbes,” he said.

Overall, though, all these pieces working in tandem to support prevention will be key, the group said. “Prevention is powerful, life-saving, and a financial necessity,” Nash said. “Focusing on products that offer long-term cleanability and durability will lead to possible interruption of transmission of dangerous pathogens and is paramount in designing for the future.”

Preventive care

Prevention, in fact, has already influenced product specification in a COVID-19 world. For example, at E4H, Schramm said the firm immediately stopped specifying carpet and is installing luxury vinyl tile only in spaces where having joints is acceptable. Additionally, designers continue to confirm with manufacturers that products will hold up against cleaning protocols before making a purchase. “That’s starting to narrow down what we can select from,” she said. Additionally, the firm is giving aesthetics the backseat for now. “We made the decision that we’re going to sacrifice aesthetics whenever we need to, to make the environment safer, and that’s what we’re doing—safety first. Materiality has never been more important, and to our vendors, this is a call to arms.”

Orcutt/Winslow’s Wilcynski agreed. “Let’s face it, a lot of safety has been going on over aesthetics, in grocery stores, everywhere,” she said, referring to now-ubiquitous acrylic screens. But on a deeper level, the pandemic has opened more conversations about infection control and the role design can play. She recalled years ago when infection prevention staff had to fight for solutions like solid surface countertops that her firm now specifies for most projects. “After COVID-19, people are talking about infection prevention—it’s everywhere. Everyone talks about COVID-19 and how not to get it,” she said.

And that includes patients, who are now more observant than ever. “The perception of cleanable is very important. When I’m designing fabrics now, I’m thinking about will someone want to sit in that chair, how will that wear, and how will that wearability affect someone’s perception of if this room is clean or not?” Wolfe said. As a cancer patient herself navigating a COVID-19 world, she shared that even a stained piece of furniture might make her question an environment. “It makes me feel unclean, so it’s important that there are the right products and that the patients feel [the room] is clean.”

That fact is requiring healthcare organizations to strike a balance between what’s necessary and what’s expected. Boldt shared that Advocate Aurora Health found that with staff members wearing appropriate personal protective equipment, acrylic barriers weren’t needed for infection control; however, a consumer survey showed that patients preferred seeing them. “We put acrylic up in a couple key locations, just because the customers felt safer coming back to the environment—not because it was preventing [COVID-19],” she said. Understanding that dynamic and its enduring nature will be critical to developing future products, too. “What COVID has done is caused us to go forward and think about what’s next. Even when we’re done with this, emotionally, we’re not done,” Wolfe said.

And, so, just as payment models shifted interest in infection control initiatives, Schwieterman said consumer interest will now bring that value proposition to a whole new level. “In my opinion, [infection control] changed from a stick, where the industry was kind of forced to go there from a payment model, to a carrot, where now every patient is fully aware of the infection risk that they encounter and are asking for this, as well. It’s blossomed into a full-blown critical need at the end-user site,” he said.

The long term

Anticipating what’s to come in the wake of COVID-19, Schwieterman said the pandemic stands to completely change the infection control landscape, beginning with expanding the range of buyers—especially as “there’s a much deeper risk pool when it comes to pathogens beyond COVID-19,” he said. “I think what this has identified is an unmet need.” And that critical need isn’t just being felt in the healthcare environment. For example, Alan said InPro is receiving calls from hospitality companies exploring infection protection options. “There’s a lot that’s going to change in different market segments combatting the same issue,” he said.

For healthcare, specifically, what product investments will be made going forward isn’t yet certain, but some solutions are already emerging to support prevention initiatives. Schramm at E4H is exploring the integration of handwashing sinks outside of clinical spaces, building them into waiting rooms where the station is potentially plumbed in to accommodate a full coffee kiosk. “How can we give more opportunities to make users of healthcare systems feel safer?” she said. Similarly, Wilcynski said she recently designed an ambulatory surgery center with a handwashing sink placed adjacent to the main concierge desk, allowing staff to request patients to wash their hands before being given an iPad at registration. “You make it an experience; you make it like masks today, just something that’s more acceptable. You can do that—that’s why design is powerful. It changes the way people move through spaces,” she said.

And while new product solutions will likely be developed, existing ones are also being questioned. “We’re not continuing to design around

COVID-19, but we’re continuing to design around what is a smart design,” Boldt said of how the pandemic is influencing Advocate Aurora Health’s two in-progress hospital projects. For example, in addition to cubicle curtains, the system is re-evaluating other high-touch surfaces that require cleaning such as tables in the family zones of patient rooms. “We’re asking questions about every item in the patient room,” Boldt said. The same approach is happening on the manufacturer side, too.

“This moment has allowed us to stop and pause and ask why,” McBride said. “Why do we do this? Is that necessary? Is there another way to go about this so that we’re really coming up with solutions that support modern delivery of care and the current environment and going forward?”

However, for vendors, part of answering that charge in a meaningful way is providing evidence that cuts through the infection control noise that COVID-19 has stirred up. “Claiming something isn’t good enough anymore,” Schwieterman said. “We’re doing a lot of misinformation management right now as manufacturers. The only way to filter between the noise is a peer-reviewed, high-quality study to prove something,” he said. Alan agreed, but added that true evidence-based design—products that have been specified, used, and proven in the field—is necessary but difficult to achieve, as few organizations are able to dedicate time to the pursuit. “You have to be able to control an environment and start weeding out variables to determine what works and what doesn’t,” he said. And as new solutions are introduced, participants urged the industry to be careful in specification and trusting manufacturer claims. “I like to say, ‘prove it to me,’” Schramm said.

Even as COVID-19 persists, the infection control playing field is likely forever changed—especially as attention has been placed not only on this pathogen but on the arguably more dangerous and transmissible ones to come and the ways that product solutions play a role in prevention. And as collaboration between industry members emerges as a key to success, the group stressed the importance of continuing the conversation, asking questions, and potentially even developing a new solution—together. “Manufacturers are willing to have those calls, maybe now more than ever. You learn more, and something much better comes out of it,” Barkan said.

Jennifer Kovacs Silvis is editor-in-chief of Healthcare Design. She can be reached at jennifer.silvis@emeraldx.com.